Team-Based Implementation of an Exclusive Human Milk Diet.

BACKGROUND: The University of Virginia neonatal intensive care unit is a 51-bed unit with approximately 600 to 700 admissions per year. Despite evidenced-based clinical care, necrotizing enterocolitis (NEC) and feeding intolerance remained problematic. PURPOSE: In September 2016, the neonatal intensive care unit implemented an exclusive human milk diet (EHMD) for infants born 1250 g or less with the goal of reducing NEC, feeding intolerance, parenteral nutrition use, and late-onset sepsis. Length of stay, bronchopulmonary dysplasia (BPD), and retinopathy of prematurity were also evaluated. METHODS: A work group developed systems for charging and documenting products used in an EHMD. Outcomes were compared with a control group of similar infants born prior to the availability of the EHMD. RESULTS: Infants who received an EHMD had significantly fewer late-onset sepsis evaluations (P = .0027) and less BPD (P = .018). While not statistically significant, less surgical NEC was also demonstrated (4 cases vs 1 case, which was 57% of total NEC cases vs 14.3%) while maintaining desirable weight gain and meeting financial goals. IMPLICATIONS FOR PRACTICE: A multidisciplinary team that implements financial and documentation systems can provide a sustainable clinical practice that improves patient outcomes. Ongoing evaluations of clinical and financial data provide valuable information to guide future clinical practices related to the EHMD. IMPLICATIONS FOR RESEARCH: Future research on the anti-inflammatory effect of an EHMD is needed to provide direction regarding a potential dose-dependent response for reduced BPD rates and severity. The role of human milk and prevention or mitigation of sepsis is not fully understood, but the reduction of the number of late-onset sepsis evaluations may support the relationship between an EHMD and infection protection. Exploring clinical and financial outcomes for implementing the EHMD in infants born more than 1250 g remains a key area for research.

The disproportionate cost of operation and congenital anomalies in infancy.

BACKGROUND: Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life. METHODS: Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system. RESULTS: In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n = 32,614) or had a diagnosis of a severe congenital anomaly (n = 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n = 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies. CONCLUSION: In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.

Human Milk and Clinical Outcomes in Preterm Infants.

The LOVE MOM cohort (Longitudinal Outcomes of VLBW Infants Exposed to Mothers' Own Milk; NIH: R010009; Meier PI) enrolled 430 infants with very low birth weight (VLBW) between 2008 and 2012 to study the impact of the dose and exposure period of MOM during hospitalization in the neonatal intensive care unit (NICU) on potentially preventable complications of prematurity and their associated costs. In this prospective study, MOM and formula feedings were calculated daily (mL), medical diagnoses for NICU morbidities (necrotizing enterocolitis [NEC], late-onset sepsis [sepsis], and bronchopulmonary dysplasia [BPD]) were confirmed independently by 2 neonatologists, and propensity scoring was used to analyze covariates. Neurodevelopmental outcome was measured for a subset of 251 LOVE MOM infants at 20 months of age, corrected for prematurity (CA). Data revealed a dose-response relationship between higher amounts of MOM received during critical NICU exposure periods and a reduction in the risk of NEC, sepsis, BPD, and their costs, as well as higher cognitive index scores at 20 months CA. MOM appears to function via different mechanisms during NICU exposure periods to reduce the risk of potentially preventable complications and their costs in VLBW infants. Institutions should prioritize the economic investments needed to acquire, store, and feed high-dose MOM in this population.

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery.

OBJECTIVE: Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. METHODS: We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. RESULTS: Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. CONCLUSIONS: Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery.

The investment case for preventing NICU-associated infections.

BACKGROUND: Nosocomial [hospital-associated or neonatal intensive care unit (NICU)-associated] infections occur in as many as 10 to 36% of very low-birth-weight infants cared for in NICUs. OBJECTIVE: To determine the potentially avoidable, incremental costs of care associated with NICU-associated bloodstream infections. STUDY DESIGN: This retrospective study included all NICU admissions of infants weighing 401 to 1500 g at birth in the greater Cincinnati region from January 1, 2005, through December 31, 2007. Nonphysician costs of care were compared between infants who developed at least one bacterial bloodstream infection prior to NICU discharge or death and infants who did not. Costs were adjusted for clinical and demographic characteristics that are present in the first 3 days of life and are known associates of infection. RESULTS: Among 900 study infants with no congenital anomaly and no major surgery, 82 (9.1%) developed at least one bacterial bloodstream infection. On average, the cost of NICU care was $16,800 greater per infant who experienced NICU-associated bloodstream infection. CONCLUSION: Potentially avoidable costs of care associated with bloodstream infection can be used to justify investments in the reliable implementation of evidence-based interventions designed to prevent these infections.

[The shortening of the duration of pregnancy due to smoking and associated costs for perinatal health care in Germany]. / Erhöhung der Frühgeborenenrate durch Rauchen in der Schwangerschaft und daraus resultierende Kosten für die Perinatalmedizin in Deutschland.

BACKGROUND: As about 20 % of pregnant women smoke, 137,000 of the 685,795 neonates delivered in Germany in 2005 have been affected by smoking during pregnancy. Caring for neonates born prematurely because of smoking results in additional costs. We have attempted to estimate these costs. MATERIAL AND METHODS: Data of 1,815,318 pregnancies were collected from the German perinatal statistics of 1995-1997. In 876,645 cases there was information regarding smoking. Of these, 699,134 pregnant women were non-smokers and 177,511 were smokers. To determine the number of preterm births due to smoking, we compared the distribution of the duration of pregnancy of the non-smoking cohort to that of the smoking cohort. From the difference between this and the actual distribution of the duration of pregnancy among smokers we determined the number of additional preterm births caused by smoking. For the analysis of the associated costs we used the actual costs of care and daily rates used in neonatology. RESULTS: For 2002 we estimate 43 million Euros of additional costs due to neonates born prematurely because of smoking. CONCLUSIONS: We present a rough estimate of the additional health care costs for neonates because of smoking. Costs were estimated only with regard to premature deliveries. Other effects of smoking during pregnancy on neonatal health were not considered. More detailed cost analyses will likely reveal even higher costs.

Outcome and hospital cost for infants weighing less than 500 grams: a tertiary centre experience in Taiwan.

AIM: To determine the outcome and hospital cost for infants weighing < or =500 g at a tertiary centre in Taiwan. METHODS: We retrospectively reviewed the medical records of infants who were born alive with birthweight < or =500 g at the National Taiwan University Hospital from 1997 to 2004. Their outcome and hospital cost were analysed. RESULTS: A total of 168 infants were included for analysis that 146 of them died after compassionate care in the delivery room and 22 received postnatal resuscitation. The infants who received resuscitation were more likely to have higher birthweights, older gestational ages and multiple births compared with those who received compassionate care. After resuscitation, five of the infants died and 17 were admitted to neonatal intensive care unit (NICU) for further management. Subsequently, 12 infants died and five infants survived to discharge. Two infants were discharged against advice and died within days. After exclusion of those receiving compassionate care, the NICU survival rate was 22.7% and the long-term survival rate was 13.6%. The most common early morbidities were respiratory distress syndrome, intraventricular haemorrhage and patent ductus arteriosus, whereas the late morbidities included cholestatic jaundice, retinopathy of prematurity and chronic lung disease. The average total hospital costs for the NICU survivors with birthweight < or =500 g was US $42,411 and the average hospital cost per day was US $350. CONCLUSION: Exclusive compassionate care was given to the majority of the infants weighing < or =500 g in Taiwan. The survival rate remained low in these marginally viable infants.

State estimates of neonatal health-care costs associated with maternal smoking--United States, 1996.

Smoking during pregnancy can cause poor outcomes for both the pregnant woman and her unborn child and also result in added health-care expenditures. To characterize costs by state, CDC analyzed pregnancy risk surveillance and birth certificate data to estimate the association between maternal smoking and the probability of infant admission to a neonatal intensive care unit (NICU). Neonatal health-care costs, in 1996 dollars, were assigned on the basis of data from private health insurance claims. This report summarizes the results of that analysis, which estimated smoking-attributable neonatal expenditures (SAEs) of 366 million dollars in the United States in 1996, or 704 dollars per maternal smoker, and indicated wide variations in SAEs among states. These costs are preventable. States can use these data to justify or support their prevention and cessation treatment strategies.

The impact of National Health Insurance on neonatal care use and childhood vaccination in Taiwan.

The objective of this study was to assess the impact of National Health Insurance (NHI) on the utilization of neonatal care and childhood vaccination in Taiwan. Data are selected from two nationwide maternal and infant surveys undertaken in 1989 and 1996, which were funded by the Department of Health. The questionnaire was administered in all 23 administrative districts, including two metropolitan areas - the cities of Taipei and Kaohsiung. The first and second cohort consisted of 1641 and 3499 infants, respectively. This study used a bivariate probit estimation procedure to examine the factors that determine the probability of neonatal care use and vaccination by pooling the 2 years. Generally, the mothers who are older, more educated and more satisfied with birth delivery services were found to be more likely to use neonatal preventive care. The likelihood of receiving such care also tends to rise with advancing gestational age and higher probability of neonatal complication (icterus neonatorum) and being born in a hospital. The likelihood of care was also found to vary regionally with northern neonates having higher odds of receiving preventive care than non-northern neonates. In spite of having an insignificant impact on the use of care, NHI does lessen the inequality in use of these two services in various regions. However, regional variations in neonatal care use still exist. Residents of the southern area remain less likely to receive neonatal care than those of the northern area after NHI. This finding deserves serious consideration when attempting to design effective policies, such as expanding medical institutions in the aboriginal southern areas so as to increase the accessibility of such health care.

A critical review of cost reduction in neonatal intensive care. I. The structure of costs.

Neonatal intensive care is expensive. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under intense pressure to find strategies for cost reduction for neonatal services. Few neonatal clinicians are trained in economics, management, or accounting, and few hospital administrators are familiar with neonatal intensive care. In this review, we describe the structure and sources of hospital costs and the accounting systems needed to isolate and measure such costs. We discuss where efficiencies might be found and consider specific issues in capitated settings such as health maintenance organizations in the United States, the Canadian health care system and the National Health System in the United Kingdom.

[Diagnosis-related groups and neonatal surgical patients]. / Diagnoserelaterte grupper og neonatalkirurgiske pasienter.

Diagnose Related Groups (DRG) are defined on the basis of the principal diagnosis, secondary diagnoses, procedures, age, sex and discharge status, and were developed to improve hospital productivity and efficacy. Existing code systems do not cover all medical specialties equally well; examples are neonatal medicine, cancer treatment and rehabilitation. We have developed a prospective method to measure actual costs related to patients individually. The major element in this method is based upon the hospital stay being divided into types of treatment with different resource requirements: heavy intensive care, light intensive care, intermediate care and ordinary care. In addition, costs related to surgery and other procedures are measured. Our method was used to calculate costs related to neonatal surgery due to various inborn diseases in the gastrointestinal tract and the urinary system. All patients needed immediate care and competent medical intervention. Mean costs for the group was NOK 291,181 while total reimbursement to the hospital was NOK 100,390, resulting in a net negative balance of NOK 190,970. Neonatal surgery does not seem to be adequately covered by the DRG system. This complex patient group provides a comprehensive test of the prospective method, and after evaluation we feel that it can be used in most other patient groups to verify actual cost.

A cost-effectiveness analysis of the application of nitric oxide versus oxygen gas for near-term newborns with respiratory failure: results from a Canadian randomized clinical trial.

OBJECTIVE: To conduct a cost-effectiveness analysis of the use of inhaled nitric oxide (NO) vs. oxygen administered to near-term (gestational age > or =34 wks) newborns with severe respiratory illness that were referred for consideration of extracorporeal membrane oxygenation (ECMO). DESIGN: The cost-effectiveness analysis is based on outcome and utilization data from two multicentered randomized clinical trials conducted by the Canadian Inhaled Nitric Oxide Study group, one for patients with congenital diaphragmatic hernia (CDH) and one for patients without CDH. Data from the western Canadian ECMO center were used to establish costs. SETTING: Patients were cared for in Canadian regional neonatal intensive care units, including two ECMO centers. Air transport was used for transporting patients between centers. PATIENTS: Term and near-term newborns with severe respiratory illness who were receiving maximum conventional therapy and whose oxygenation index was >40. INTERVENTIONS: Patients randomly received NO or oxygen. If their conditions deteriorated, they qualified for ECMO. Not all that qualified for ECMO received it because of individual parent/ physician preferences. MEASUREMENTS AND MAIN RESULTS: The cost-effectiveness ratio was the ratio of net cost (including neonatal intensive care, ECMO, and transport) to net outcome (survival) for the two interventions. For non-CDH cases, the cost-effectiveness ratio was $36,613 (Canadian) per life saved; the confidence intervals were wide and the results were not statistically significant. For CDH patients, the death rate was lower for oxygen and the oxygen patients cost less; the results were not statistically significant. CONCLUSIONS: The small numbers of patients in the trials precluded significant results. Further, our results have a short-term time horizon (discharge to home or death). Thus, for non-CDH patients, the favorable ratio provides very qualified evidence in favor of NO.

Costo día por recién nacido en la unidad de terapia intensiva neonatal de la Maternidad Concepción Palacios / Cost for day of newborn in the intensive neonatal care unit of the Maternidad Concepción Palacios

La Maternidad Concepcion Palacios, asiste entre 2300 y 2400 nacimientos por mes, de los cuales sólo un 0,67 por ciento ingresan a la unidad de cuidados neonatales intensivos. Se determinó el costo de cada paciente asistido en la unidad, con el objetivo de dar a conocer los resultados y presentar el minucioso método de cálculo de esta evaluación económica. La investigación se realizó durante el mes de marzo de 1996, resultando un total de 645754 bolívares por cada neonato que atendió la unidad; con un costo al momento del ingreso de 26521 y un gasto diario de 45699 bolívares. Contamos con un promedio cama-día de 8, un porcentaje de ocupación del 85 por ciento, un promedio de estancia de 13 días y un intervalo de sustitución de 3 días. De la unidad egresan mensualmente 13 casos con una mortalidad del 42 por ciento

The impact of prenatal exposure to cocaine on newborn costs and length of stay.

OBJECTIVE: Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs. DATA SOURCES AND STUDY SETTING: All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992. STUDY DESIGN: A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection. DATA COLLECTION/EXTRACTION METHODS: Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition. PRINCIPAL FINDINGS: Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.